Child bicyclist injuries: are we obtaining enough information in the emergency department chart?

ABSTRACT

OBJECTIVE: The purpose of this study was to assess the range of information relevant to bicyclist injury research that is available on routinely completed emergency department medical records. METHODS: A retrospective chart review of emergency department medical records was conducted on children who were injured as bicyclists and treated at an urban level I pediatric trauma center. A range of variables relevant to bicyclist injury research and prevention was developed and organized according to the Haddon matrix. Routinely completed free text emergency department medical records were assessed for the presence of each of the targeted elements. In addition, medical records of seriously injured patients (for whom a more structured medical record is routinely used) were compared to free form records of less seriously injured patients to identify differences in documentation that may be related to the structure of the medical record. RESULTS: Information related to previous medical history (96% of records), diagnosis (89%), documentation of pre-hospital care (82%), and child traumatic contact points (81%) were documented in the majority of medical records. Information relevant to prevention efforts was less commonly documented identification of motor vehicle/object involved in crash (58%), the precipitating event (24%), the location of the crash (23%), and documentation of helmet use (23%). Records of seriously injured patients demonstrated significantly higher documentation rates for pre-hospital care and child traumatic contact points, and significantly lower documentation rates for previous medical history, child kinematics, main body parts impacted, and location of injury event. CONCLUSIONS: Routinely completed free text emergency department medical records contain limited information that could be used by injury researchers in effective surveillance. In particular information relating to the circumstances of the crash event that might be used to design or target prevention efforts is typically lacking. Routine use of more structured medical records has the potential to improve documentation of key information.